HEALTH INFORMATION QUESTIONNAIRE

We comply with all federal HIPPA privacy standards. Your health information is kept confidential

Please correct the errors described below.

Patient Information

Emergency Contact Information

Add another emergency contact if you wish

Add another complaint or region

In order to properly assess your condition, we must understand how much your condition(s) have affected your ability to manage everyday activities. For each item, please select the number which most closely describes your condition right now

Review of Systems

Are you currently having, or have you had problems or treatment for: (check all that apply)

Social History / Health Habbits

McDaniel Chiropractic Center Notice of Privacy Policy

This Notice of Privacy Policy describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment or health care operations (TPO)

HIPAA Authorized Representative - Authorization for private information disclosure. I hereby authorize McDaniel Chiropractic Center to share information regarding by appointments, treatment or office finances with the person(s) listed below.

( Without expressed authorization, please realize that we will not provide any information to another party, even a spouse. Often patients will list a spouse, partner or family member who may contact us about appointment times or other such information. This authorization may be revoked by you at any time.

Your information will be encrypted.

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